Nurse charting stuff she did not do.

[Peetz]

I work in LTC/RH and we are having to deal with family of a resident over a wound. There is talk of lawyers, suits and what not. I found out that the documentation for this "wound" was poor if at all. There was a signature that another nurse has preformed a skin audit the same day and it was negative, yet did not fill out the paperwork for skin audits ( she never does, even after repeated complaints to the DON.) There are several resident she charts that she does treatments on and I know they are not getting done. I feel this is another treatment that she signed off on and did not actually do.

Has anyone had this happen and what was the outcome. This RN has been there many years and feels she is un-fire-able. I would really like to see this person reprimanded for her actions, simply so things change for the sake of the patients. I believe in education first and discipline second, but she has been told multiple times about skin audit forms and just refused to take part in any change.

[LouisVRN, RN]

This in my opinion is not something that warrants a "courtesy reminder" to the nurse. Any falsification of the documentation imo is an immediate incident report. I always write it like Cuddles stated. Something like if pt is alert and oriented " pt denies dressing being changed today. Dressing observed to be soiled. Date on dressing 11/30/11 initials ABC. Dressing removed, wound observed to be (accurate measurements and description of wound and peri wound area. Dressing change performed per x orders."

[PsychNurseWannaBe, BSN, RN]

I do not have any advice about colleagues not doing things they are supposed to but I do have some experience with families that seem to be falling short of caring for their dependents.

Be objective in your charting for your shift. Instead of writing "Pt's diaper was not changed" I write something like "Pt's diaper is heavily soiled, perineal area moist and red...."

You could also mark and date the dressings you apply so that you can plainly state "Dressing states "11/15/11 (your initials and time of change). Dressing removed. Wound (looks worse than before ew yuck but be objective hehe)."

Diaper?? Are you talking about a baby? Because if you are talking about an elderly person, the term is brief. Diaper is degrading.

[maelstrom143]

Documenting care that has not been given is considered fraud, much like a doctor writing a progress note and stating he saw a patient during rounds when he did not. I really appreciate and respect the people I work with and would not do them harm for the world. However, neither would I knowingly hurt another human being by being negligent in my duty to them.

If you see a person abusing a child or animal, know that it is wrong, and walk away without doing anything about it, then you are worse than the abuser. Why is it ok then to see that a patient's rights and needs are being neglected and just walk away?

We grow angry and judgmental of the Chinese people who saw the injured toddler and left her to be run over again, eventually to die of her injuries, raining verbal abuse on those we saw as doing nothing. How are we any better than they if we see abuse happening right under our noses to the weakest in our society and just walk away, more willing to protect one of our own than those that were entrusted to our care?

I may feel bad for the nurse who may lose her job. However, she chose to chart fraudulently. She chose to betray the trust of the people under her care. She chose to endanger others without regard to their well-being. She is a competent adult. This is not about us against the institution, but about doing what is right because it is the right thing to do, even if no one is watching to make sure we do the right thing.

We make choices and we must live with the consequences of our actions.

http://www.excellenceinlearning.net/courses/111.doc

[PsychNurseWannaBe, BSN, RN]

Where I work, dressings are to be initialed with the date. If the treatment wasn't done, it is treated like a med error. I check the TAR and if it is initialed as done, but the dressing has an older date from a previous treatment change, then I talk to the nurse about doing treatments as orders and the fact that they are falsifying a medical document regardless of intent.

[TeenyTinyBabyRN, BSN, RN]

You don't have to be "nosey" to realize someone is falsifing documents. We had a nurse fired because when she had to leave early(1200), the nurse taking over for her discovered she had filled out her assessments for the whole 12 hours, including hourly vital signs.

Also, where I work, we change Broviac dressings once a week. When I am checking my chart and making a list of the things I need to do that day, I look in the box to see when the last time the dressing was changed. If it states it was changed yesterday, but when I go to do my assessment, I see that the dressing still has my intials on it, from when I changed it last week, I know it was falsified.

[caliotter3]

One of the nurses on my home health case only charts once every month or six weeks. She will chart ahead. Patient was recently hospitalized and there are her initials on the MAR that she gave meds two or three times while the patient was in the hospital. I don't know how it is that the supervisors see this month in and month out, and feel it is not necessary to do anything about it.

[xtxrn, ASN, RN]

One of the nurses on my home health case only charts once every month or six weeks. She will chart ahead. Patient was recently hospitalized and there are her initials on the MAR that she gave meds two or three times while the patient was in the hospital. I don't know how it is that the supervisors see this month in and month out, and feel it is not necessary to do anything about it.

It's falsification of documents - hope that resident comes back, and there's no legal backlash, because that just added a few decimal points to the asking damages.

I've been deposed (HORRIBLE experience- and the case was nuts)....they blow up the pages of the mistakes into poster size- with highlighted areas, and demands for explanations. They ask "gray" questions, and want yes/no answers. It's hell.... hope this nurse enjoys court if something happens and the family decides to sue- she can't un-chart stuff for when the resident was gone.

The supervisors get sued too.....in my situation, it was the admin, DON, myself, and weekend day nurse. Screwy charting will KILL any chance of a decent outcome (by that I mean NO damages awarded). There were some I&O 'holes' that were a big problem. (on some of the CNA charting. This was a patient who would NOT take in fluids.... the doc didn't answer faxes or phone calls. She'd had a GI bleed to the point of renal failure- and the family refused dialysis- she was 97 years old. The fluid was so far beyond edema that sh had pools under the wheelchair.

Chart what is done- no more, no less. :)

[Peetz, BSN]

Your DON needs to know of the "talk" of lawsuits, etc. immediately, as well as anything you have on the state of the resident's wound and any documentation relating to it.

What is your position? Co-worker? Supervisor?

I am the other day shift charge nurse. It was the family that was using the words like lawyer, suit and neglect repeatedly during their visit. I am only on shift a few days a week due to my schedule at school , I am half way through my BSN. I understand that staffing is small, the nurses are asked to do more than we have time for, but if something does not get done it can be picked up by the next shift.

The DON is aware of this issues and it was going on for a while before I came on shift. My issue is when they asked to see the would care documentation, there wasn't any to find which really looked bad for the company.

Each week I do would documentation on all current wounds that are not due to surgery. I get a list of who has wounds and measure ,describe and document them. This person was not on my list, I only had two, which seemed small so I asked the DON if that was truly all we had. ( which is a really good thing) She assured me it was.

She gets her information from weekly skin audit sheets, no sheet turned in on this patient and the mark in the treatment book was negative for skin audit. ( meaning no issues) That was day shift on the 29th. That evening family came in ( angry over another issue) and observed her being put to bed, the wound that was observed at that time was a large excoriation wound on the buttock. There is no way that would have been missed with a skin audit that morning.

[Peetz, BSN]

What is this really about, patient care or your desire to see this nurse gone? How do you know she is improperly documenting? Is it your job to audit charts? Are you in a position to supervise her?

There are a lot of posts here about nurses wanting to see other nurses disciplined/terminated, all under the guise of "patient care." I wonder sometimes if claiming to be an advocate for the patient makes retaliation toward another nurse easier to fly under the radar.

This is about proper pt care. I am a strong advocate for education before discipline and feel a strong dose of re-education is what this rn needs most.

I know there is documentation of treatments that have not been done. I feel she does this to make herself look good in the scene that she is getting everything done.

She as been told repeatedly to fill out the proper paperwork where wounds and skin are concerned and responds with a a negative attitude about the form being " new " and not needed.

She has been at the same facility for many years and has no respect for other nurses, they are all" new and temporary" as she said. " she will be gone soon so why should I change to suit her." a quote about our most recent DON.

I do not want to make my small working environment more stressful than it is, so "reminding' her of how things are supposed to be done is useless, she responds with rude, ill-educated responses.

The facility is barely making it, a law suit could bury this small facility. We are a good facility, I would hate to see that happen.

I have no desire to retaliate, she has never done anything to me personally to warrant payback. Honestly I feel that payback is childish and a waste of energy. I did not get into nursing to stand by and watch lazy people do a half baked job of patient care.

[Peetz, BSN]

I do not have any advice about colleagues not doing things they are supposed to but I do have some experience with families that seem to be falling short of caring for their dependents.

Be objective in your charting for your shift. Instead of writing "Pt's diaper was not changed" I write something like "Pt's diaper is heavily soiled, perineal area moist and red...."

You could also mark and date the dressings you apply so that you can plainly state "Dressing states "11/15/11 (your initials and time of change). Dressing removed. Wound (looks worse than before ew yuck but be objective hehe)."

My charting is not in question in this matter. We date and time all briefs and all wound dressings are supposed to be dated and initialed.

[Cuddleswithpuddles]

Diaper?? Are you talking about a baby? Because if you are talking about an elderly person, the term is brief. Diaper is degrading.

Yes, I am referring to a baby.

[Peetz, BSN]

Where I work, dressings are to be initialed with the date. If the treatment wasn't done, it is treated like a med error. I check the TAR and if it is initialed as done, but the dressing has an older date from a previous treatment change, then I talk to the nurse about doing treatments as orders and the fact that they are falsifying a medical document regardless of intent.

This is the same indecent that started the dating and initialing of bandages. I found a bandage that had a smiley face on it, one I did a few days prior yet it was marked in the treatment book it had been changed. If things like this are done one time with one patient , it makes me wonder how many others are being mistreated and not having wounds properly cared for.

I was the wound care RN for a while when census was up and before medicare cuts almost killed up.